At the start of a sick child (2 months to 5 years) consultation Ask the mother what the child’s problems are. Determine if this is an initial or follow-up visit for this problem.

IMCI Case Management Classification Focused Assessment Need to Refer Danger signs Main Symptoms Nutritional status Immunization status Other problems Specific treatment Home management Counsel & Follow-up Treatment Counsel caretakers Follow-up Identify treatment Treat

Check for general danger signs Ask: Not able to drink or breastfeed, Vomits everything, Convulsions, or Look: Abnormally sleepy or difficult to awaken Need to Refer (except in severe dehydration)

Ask about the main symptoms Cough or difficulty in breathing Diarrhea Fever Ear problem

Cough or difficulty in breathing Ask: For how long? Look: Count RR Chest indrawing Stridor The child must be calm.

Any general danger sign or Chest indrawing or Stridor SEVERE PNEUMONIA OR VERY SEVERE DISEASE 1st dose of antibiotic Vitamin A Breastfeeding/sugar water URGENT REFERRAL

Fast breathing 2 – 12 months old: ≥ 50/minute 1 year or older: ≥ 40/minute PNEUMONIA Antibiotic for 5 days Relieve cough with safe remedy Advise mother on danger signs Follow up in 2 days

or a very severe disease NO PNEUMONIA: COUGH OR COLD No signs of pneumonia or a very severe disease NO PNEUMONIA: COUGH OR COLD If cough ≥ 30 days  refer to hospital for assessment Relieve cough with safe remedy Advise mother on danger signs Follow up in 5 days if no improvement

Diarrhea: Classify For dehydration Persistent diarrhea Blood in the stool

Classify for dehydration 2 or more of the following: Abnormally sleepy/difficult to wake Sunken eyes Not able to feed/drinking poorly Skin pinch goes back very slowly SEVERE DEHYDRATION Plan C

Plan C: To treat dehydration quickly IV fluid: LRS 100 ml/kg body weight (in 6 hrs for infants; 3 hrs for children) NO IV treatment within 30 minutes NO Oresol/NGT

Plan C: To treat dehydration quickly Oresol/NGT NO Oresol p.o. NO URGENT REFERRAL

Classify for dehydration 2 of the following: Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly SOME DEHYDRATION Plan B

Plan B: Treat some dehydration with ORS Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart. Age < 4 mos 4-12 mos Amount 200-400 400-700

Plan B: Treat some dehydration with ORS Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart. Age 12 mos-2 yrs 2-5 yrs Amount 700-900 900-1400

Plan B: Treat some dehydration with ORS Show the mother how to give Oresol to the child: frequent sips from a cup If the child vomits, wait for 10 minutes. Then continue, but more slowly. Continue breastfeeding if the child wants to breastfeed. If the child develops puffy eyelids, stop ORS.

Plan B: Treat some dehydration with ORS After 4 hours: Reassess the child & classify for dehydration. Select appropriate plan. Begin feeding the child in the health center.

Classify for dehydration Not enough signs to classify as SEVERE DEHYDRATION or SOME DEHYDRATION NO DEHYDRATION Plan A

Plan A: Treat diarrhea at home Give extra fluid. Up to 2 yrs 50 – 100 ml after each LBM 2 -4 yrs 100 – 200 ml after each LBM Continue feeding. Know when to return.

Persistent diarrhea: 14 days or more + Dehydration=severe persistent diarrhea Treat dehydration Give Vitamin A Refer to hospital

Persistent diarrhea: 14 days or more No dehydration=persistent diarrhea Advise regarding feeding Give Vitamin A Follow up in 5 days

Blood in the stool = dysentery Oral antibiotic for shigella for 5 days Follow up in 2 days

Fever: (history/temperature 37.5°C or above) Malaria risk? Measles now or w/in last 3 mos Dengue risk?

Fever: Ask about malaria risk Residing in endemic area? OR: Travel & overnight stay in endemic area, or Blood transfusion w/in past 6 mos

Malaria risk + Blood smear Ask: Duration of fever? Present everyday? Look: Stiff neck Runny nose Other signs of measles

Malaria risk + any general danger sign or stiff neck Very severe febrile disease/malaria Quinine (under med. supervision) 1st dose of antibiotic, Paracetamol Urgent referral

Malaria risk +, blood smear + No runny nose, no measles Oral antimalarial Paracetamol Follow up in 2 days > 7 days fever  hospital for assessment

No malaria risk Any general danger sign or stiff neck Very severe febrile disease 1st dose of antibiotic, Paracetamol Urgent referral

Severe complicated measles Measles now or w/in last 3 mos Clouding of cornea or Deep or extensive mouth ulcers Severe complicated measles 1st dose of antibiotic, Vitamin A Urgent referral

Measles now or w/in last 3 mos Pus draining from the eye or Mouth ulcers Measles with eye or Mouth complications Vitamin A Tetracycline eye ointment Gentian violet Follow up in 2 days

Measles now or w/in last 3 mos No other signs Vitamin A

If there is Dengue risk Bleeding gums, nose, in vomitus or stools Black vomitus or stools Persistent abdominal pain Persistent vomiting Skin petechiae Slow capillary refill No signs, but fever > 3 days  Tourniquet test

Slow capillary refill Indicates poor skin perfusion Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.

Any of the danger signs or + tourniquet test Severe Dengue hemorrhagic fever If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS Any other signs of bleeding  Plan C Urgent referral Do not give aspirin

Ear problem: tender swelling behind ear Mastoiditis 1st dose of antibiotic Paracetamol for pain Urgent referral

Ear discharge < 14 days or Ear pain Acute ear infection Antibiotic for 5 days Paracetamol for pain Wicking Follow up in 5 days

Ear discharge for 14 days or more Chronic ear infection Wicking Follow up in 5 days

Visible severe wasting or Edema on both feet or Severe palmar pallor Severe malnutrition or severe anemia Vitamin A Urgent referral

Some palmar pallor or Very low weight for age Anemia or very low weight for age Assess for feeding problem Pallor: iron & Mebendazole in children > 2 yrs Wt for age very low: Vitamin A